EHR and EMR have been in our vocabulary for nearly 20 years. Since the 1990’s, clinical environments have increasingly relied on technology to function and improve patient care. Today, our methods are becoming incredibly sophisticated, particularly following the application of Stage 3 of Meaningful Use in 2016. Because of this, it’s important to take a look at a commonly misunderstood distinction: EHR (electronic health records) and EMR (electronic medical records).

The Basics of EHR vs EMR

Back in 1995, one could arguably use EHR or EMR interchangeably. This is because electronic medical records systems were just that: an electronic version of the medical chart. But as the years have gone by, our technological functionality became more robust, stretching far beyond the exam room or even the clinical setting. In fact, it’s very common now for the patient to have access to their own records, physician communication, and more all from within their home.

It is for this reason that the Office of the National Coordinator for Health Information Technology (ONC) has made a detailed study on EHR vs EMR.

How Records Systems Affect Different Parties

One way to better understand records systems in healthcare is to consider how those systems affect different parties. Let’s take a look at EHR vs EMR systems in terms of three different major parties in healthcare.

Patients –Improving patient outcomes is one of the largest and most important objectives of healthcare records systems. Patients rarely cross paths with EMRs. However, they are affected by them through follow-up exams, regular checkups, and other indicators over time. EHR systems, on the other hand, enable the patient to view their health reports, contact their healthcare providers, view referrals, pay their bills, and much more.

Providers –For providers, records systems not only help to improve patient care through improved data accuracy and alerts such as medication contradictions, but they also help to close gaps in communication and improve clinical workflow efficiency. This is true for both EHRs and EMRs, but the advantage an EHR has over an EMR for physicians is its ability to communicate information beyond the practice to patients, specialists, hospitals, and more. EHRs “move with the patient,” as explained by the ONC, as opposed to staying solely inside the walls of one practice.

Vendors –While vendors are responsible for providing a health records system, requirements for those systems can change over time, especially for certified EHR technology. EMRs are no longer sufficient to support a medical practice and its patients. Instead, EHR systems enable vendors to offer comprehensive, customizable services to medical practices that include everything from billing, to charting, to scheduling, and more, all while staying abreast of federal requirements like HIPAA and Meaningful Use regulations.

In the end, EHR systems are a direct reflection of how far technological advancements have taken the industry of records systems in healthcare. What once was simply an electronic version of a chart has become a real-time reflection of a patient and their health. This makes an EHR more powerful to the benefit of all parties involved, but in particular, to the patient.

The Centers for Medicare & Medicaid Services is one step closer to issuing a notice of proposed rulemaking (NRPM) for the next stage of meaningful use requirements for the Medicare EHR Incentive Program.

The Office of Management and Budget (OMB) is currently reviewing the proposed rule for Stage 3 Meaningful Use that is expected to be published in February.

Few details about the requirements for Stage 3 appear in the rule submitted to the OMB by the Department of Health & Human Services as part of the Unified Agenda — that is, with the exception of the following:

In this proposed rule, CMS will implement Stage 3, another stage of the Medicare and Medicaid EHR Incentive Program as required by ARRA. We are proposing the Stage 3 criteria that EP’s, eligible hospitals, and CAHs must meet in order to successfully demonstrate meaningful use under the Medicare and Medicaid EHR Incentive Programs, focusing on advanced use of EHR technology to promote improved outcomes for patients. Stage 3 will also propose changes to the reporting period, timelines, and structure of the program, including providing a single definition of meaningful use. These changes will provide a flexible, yet, clearer framework to ensure future sustainability of the EHR program and reduce confusion stemming from multiple stage requirements.

Before any of the proposed rule’s requirements for Stage 3 Meaningful Use are enacted, the NPRM must made available for public comment which has the potential to influence the requirements of the final rule. Given the resistance CMS has faced as a result of Stage 2 Meaningful Use, the federal agency is likely to receive requests for greater flexibility and timing from healthcare organizations and industry groups.

EMRAM is an eight-step process that allows healthcare provider organizations to analyze their level of EMR adoption, chart accomplishments, and benchmark progress against other healthcare organizations across the country. Each of the stages is measured by cumulative capabilities and all capabilities within each stage must be reached before progressing.

“We’re happy to be able to confirm eClinicalWorks as an EMRAM Certified Educator,” said Blain Newton, COO, HIMSS Analytics. “EMRAM allows organizations to align IT initiatives and overall business strategy, which is essential to shaping future direction and moving the industry forward.”

Vendors achieving HIMSS Analytics Certified Educator status must pass an annual certification exam and commit to an annual educator program. This ensures they stay current with trends within the model and are equipped with the necessary knowledge to help their clients advance through the various stages.

“A major goal is having our customers utilizing the EMR the most beneficial way possible for both providers and patients,” said Girish Navani, CEO and co-founder of eClinicalWorks. “This certification will benefit organizations looking to analyze their adoption of EMR technology. We welcome being part of the program.”

For more than a decade, electronic medical records (EMRs) have been called a critical step forward in modern medicine. The idea was that transitioning from paper to electronic records would increase efficiency, safety and savings in health care. The potential for EMRs to make patient records more accessible, reduce medical errors, allow medical institutions to communicate more seamlessly and save the health care industry billions of dollars each year was too tempting to pass up.

Despite this, the reality of EMRs seems not to have lived up to the hype. EMR systems have been costly to implement and are often laborious and confusing to learn. There is no universal system that all physicians can use; instead, medical professionals are faced with more than 100 systems, all competing for users and many of which cannot communicate with one another. But perhaps most notably, these systems do not appear to improve patient care, as promised, and in some cases may make care worse.

Nevertheless, the use of EMRs has ballooned in the past 10 years. In 2005, fewer than 25% of physicians’ offices and hospitals had adopted an EMR system, but today more than 80% use one. Despite the rapid spread, the central concerns about EMR systems remain the same: high cost, lack of standardization and interoperability, privacy issues and inferior patient care (Health Aff 2005;24:1103-1117).

But even before this spike in usage, many medical professionals were already well aware of the issues. In a 2004 report, researchers who had conducted 90 interviews with EMR managers and physicians found that “most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increase resulted in longer workdays or fewer patients seen, or both, during that initial period …. Most respondents or their colleagues considered even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options and navigational aids” (Health Aff 2004;23:116-126).

In a 2013 survey conducted by RAND Health, and sponsored by the American Medical Association, physicians echoed many of the same sentiments. In fact, physicians rated EMRs as a main reason for their job dissatisfaction. Summing up the results of the report, the RAND researchers wrote: “Despite recognizing the value of EHRs [electronic health records] in concept, many physicians are struggling to use their EHRs, which they describe as negatively impacting patient care in several important ways and undermining their professional satisfaction.”

In the study, the authors interviewed 24 practices about EHRs, 22 of whom were currently using a system. On the plus side, about one-third of the physicians reported that the EHR improved their job satisfaction and 61% said it improved quality of care. These physicians noted that their EHR system enhanced their abilities to access patient data at work and at home, provided guideline-based care and tracked patients’ disease.

In contrast, many physicians also expressed concerns over their EHRs, with about 20% saying they would prefer to return to paper charts. The central issues boiled down to inferior patient interactions, an inability to exchange information between different systems and a labor-intensive and time-consuming learning curve and data entry.

“Just because something is more expensive doesn’t mean it’s better,” said Peter Kim, MD, associate professor of surgery, Albert Einstein College of Medicine of Yeshiva University, New York City, who was not involved in the study. “For instance, the EMR giant Epic received $302 million from New York City, in 2013, for use in about 11 New York City public hospitals. But even within the same system, not all Epic EMRs are alike. An EMR’s functionality depends on who is programming it as well as the local needs of the institution. The same system may end up working well in one hospital, but poorly in another.”

Although people often assume that technology will reduce errors, that also is not the case. “In our hospital, administrators try to make our EMR sound perfect, but in reality, we have encountered huge errors and have had no audits of the system,” said Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Health Science Center, Memphis.

Along these lines, Dr. Kim recalled an incident when a toxic drug dose was written for the wrong patient, which missed all of the EMR system’s checks and balances. “Although that error could have happened with the old system, it wasn’t prevented by the EMR as it should have been,” Dr. Kim said. “We still need that human element in care, where a person is checking and verifying orders.”

Regarding patient interactions, physicians in the RAND study who complained that EHRs interfered with in-person patient care found that they were forced either to divide their attention between the patient and the computer or to give patients their attention but then spend hours inputting data afterward.

“With EHRs, physicians and nurses are looking at a computer screen and have their backs to the patient,” said Dr. Voeller. “Physicians and nurses are forced to devote time to their computer, not their patient.”

Another report revealed similar results. A team at Medscape surveyed 18,575 physicians in 25 different specialties from April 9, 2014, to June 3, 2014, about their EMR use. Of those, 4%, or 743 participants, were general surgeons.

The report found that about one-third of respondents felt their EHR systems worsened clinical operations and patient services, although about the same percentage reported the opposite. In terms of patient interactions, 70% of respondents said their system decreased their face-to-face time with patients and 57% said it lessened their ability to see patients, while about one-third felt their system enhanced their ability to respond to patients and effectively manage treatment plans.

Patient privacy was another major worry for physicians, approximately half of whom expressed concern about losing patient information because of a technological malfunction or about their lack of control over who can access patient data. About 40% of participants were also concerned about HIPAA compliance and hackers getting to data.

Similarly, of physicians who opted not to purchase an EHR system, the top reason was that the technology would interfere with the doctor–patient relationship (40% of responses). The other most frequent complaints were that EHR systems are too expensive (37%), and that the incentives and penalties from the Centers for Medicare & Medicaid Services are not worth the hassle of adopting a system (32%). Other reasons were that EHRs hurt patient privacy (22%) and were too complicated to learn (16%).

The financial burden of EMRs appeared to be increasing as well. According to the Medscape survey, in 2014, 23% of respondents said their EHR system cost $50,000 or more per physician to purchase and install, whereas in 2012, only 7% of respondents said their EHR system cost that much. Another report that evaluated the cost of EHRs, using survey data from 49 community practices in a large EHR pilot project, found that “the average physician would lose $43,743 over five years; just 27% of practices would have achieved a positive return on investment; and only an additional 14% of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive” (Health Aff 2013;32:562-570).

Currently, Dr. Kim said, the federal government is forcing institutions to have an EMR system, which is driving many physicians out of business and into a hospital on a salary or into retirement.

“Besides the cost of implementation, evidence already is accumulating that doctors order more—not fewer—imaging studies when [an] EMR is used,” wrote David Cossman, MD, a vascular surgeon in Los Angeles, in a 2012 piece in General Surgery News (May 2012, page 1).

As for billing, Dr. Voeller noted, “the way we bill through EMRs lends itself to fraud because physicians can document more complex visits that come with a higher price tag and reimbursement.”

Amid the confusion and ambivalence, some surgeons are holding out hope that as companies iron out the kinks in the current systems, EMRs may eventually live up to the early hype. Others remain skeptical that there is a magic bullet that will vastly simplify and improve EMRs.

Reflecting on the current state of the technology, Dr. Cossman wrote: “The big problem is that HAL [the sinister computer in Stanley Kubrick’s film “2001: A Space Odyssey”] is once again stalking us with the sweet siren song of untold efficiencies, cost containment and protection from human fallibility if we only move over to the passenger seat and let it drive. Don’t believe a word of it. Medicine cannot be practiced on autopilot. We will crash and burn without the human touch at the controls.”

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